The one variable affecting your ophthalmology profits over which you have complete control is operational efficiency. The faster you can get patients safely in and out the door for cataract surgery, the more cases you can do in a day and the easier it will be to recoup your operating costs and remain profitable. At St. Luke's Surgical Center, our goal is to have patients in and out in 90 minutes to 2 hours, a steady pace that lets us do as many as 60 cataract cases in a day with 3 ORs going at once. Here are a dozen steps you can take (in no particular order) to achieve the same level of speed and efficiency without compromising patient safety or satisfaction.

Be consistent. Variations in practice can lead to confusion, errors and other problems that threaten to slow things down and create bottlenecks. Establish a set of standard procedures that your staff must follow for each patient during every step in the process, from pre-op to PACU. For example, when setting up the OR for the next case, our RNs and scrub techs follow the same sequence every time:

• position the patient;
• administer the last round of dilating drops;
• prep the eye;
• hook up the phaco machine;
• bring in any additional equipment needed for the case; and
• verify the lens one last time before the surgeon comes into the room.

If staff follow this set routine for every case, they don't have to stop and think, "What should I do next?" In addition to keeping things running smoothly and efficiently, consistent protocols are also an important safeguard to prevent errors.

Review financials with the patient at the start of the visit. After they've checked in and the surgical record has been started, patients at our facility meet with a patient counselor to go over the financials of their procedure. The counselors collect any co-pays, deductibles, money for premium lenses and other payments as needed so we can proceed with preparation for surgery without any financial loose ends.

Verify patient information every step of the way. As soon as a patient checks in at our facility, we verify his identifying information, the surgeon performing the procedure, the type of procedure and the surgical site and enter this information in an electronic medical record. Even though we use EMRs to keep track of this information, we also verbally re-check the patient's ID, surgeon, procedure and surgical site each time he enters a new stage in the perioperative process, including during pre-op medical clearance, assessment by an RN in the pre-op holding area and the time out in the OR immediately before the administration of anesthesia and the surgical incision. This system of checks and balances ensures that any potential errors (for example, wrong site or wrong patient) are detected and resolved early.

Use topical anesthesia and minimize sedation. Patients who don't come in with a history and physical from their primary physician meet with a medical doctor or mid-level practitioner (PA or CRNA) on the day of surgery for their pre-op medical clearance. This step is required for the majority of our patients, so we uniformly have patients present for surgery 1 hour to 1 hour and 15 minutes before the scheduled start of the procedure. We give them an abbreviated physical to determine whether they're stable and prepared to undergo the proposed surgical intervention with the proposed anesthesia. Although every patient is evaluated on an individual basis, we try to use topical anesthesia with IV sedation for the majority of our cataract cases to enhance efficiency, since topical anesthesia allows for a faster visual recovery as well as less time spent in the recovery area of our facility. Patients for whom topical anesthesia is not practical typically get a peribulbar block.

Our anesthesia team tailors the amount of sedation used to each patient's needs. Those who are particularly apprehensive and anxious will get a little more through the IV than those who are more comfortable. The goal is always to give patients as little medication as possible, which enhances both patient safety and efficiency. Our patients are often able to walk in and out of the OR on their own.

Keep patients in their street clothes. Rather than having patients change into surgical attire, let them keep their street clothes on for cataract surgery. We put a hair bonnet over their heads and cover them with an isolation or cover gown. We used to put shoe covers on them, but studies have shown that the covers have limited benefit for infection prevention, so we don't use them anymore.

Use wrist clips for cardiac monitoring. Instead of having to get under patients' clothing and attach adhesive monitoring devices, we use wrist clips for cardiac monitoring. The devices easily slip on and off, almost like a bracelet, and they can be cleaned between patients and reused.

Flip rooms. On any given day we typically use 2 or 3 ORs for cataract surgeries. As the surgeon is performing surgery in 1 room, the surgical team — which includes a circulating nurse, scrub tech and PA — in the adjacent OR is prepping, positioning and draping the next patient and setting up the room so that the surgeon can begin performing his next procedure almost immediately after finishing the previous one. Make sure you have enough staff dedicated to each room to support this fast-paced turnover model for your cataract cases.

Appoint a turnover nurse. In addition to the 1 circulating RN we have stationed in each of our operating rooms, we appoint a very experienced ophthalmic nurse to serve as the "turnover nurse." This person floats between rooms, reviewing patient records and verifying consent forms and the lenses that were picked for the case. We created this position about 5 or 6 years ago to add an extra set of eyes, ears and hands to the floor, which helps to reduce delays in the OR and gives us another measure of quality control and patient safety. If there are any issues or questions that need to be answered, the turnover nurse can resolve them before the patient heads into the OR. She may also help bring in any special equipment needed for the case, such as iris retractors or Malyugin rings for a patient at risk of floppy iris syndrome.

Use procedure packs. Simplify the process of pulling and setting up supplies for each case by ordering all the standard items you use for cataract cases, including drapes, tubing and syringes, in procedure packs. Choose the contents of your packs wisely; they should reflect the items that are least likely to change from case to case. For example, we leave gowns and gloves out of our packs since the staff changes each day and these are items that should be individualized.

Always have a fresh set of instruments ready. You should have enough instrument trays to keep a fast pace of cataract surgeries going without having to wait in between cases for a fresh tray. The number of trays sufficient for your facility will depend on the number of ORs you have open at once, your average case volume and your average case time. For us, that magic number is nine. We also have 2 instrument techs devoted entirely to sterile processing. One tech performs instrument decontamination and the other performs sterilization of instrument sets. We try to maintain a balance between having enough instrument trays to cover 3 active ORs and an efficient technique of handling and sterilizing instruments throughout the day. (We run our instruments on a full cycle using a vacuum sterilizer, which does allow for a decreased cycle time compared to a gravity displacement system.) Having separate techs dedicated solely to the processing of instrumentation frees up our scrub techs to focus on turning over rooms.

Consider upgrading your phaco machines. About 2 years ago we purchased new machines featuring enhanced fluidic management and torsional phacoemulsification technology, which delivers side-to-side, oscillating ultrasonic movement through the handpiece to improve surgeon control during surgery. These new machines let our surgeons shave about a minute or so off their procedure times. This may sound like a small gain, but when you're doing many cataract surgeries in a day, those extra minutes add up to considerable time savings. Of course, the purchase of a new phaco machine constitutes a significant capital investment on the part of your facility, so you'll need to weigh the cost of the machine against the potential benefits of new technology. For us, the decision to upgrade was based primarily on our expectation of improved outcomes. The added benefit of shortening intraoperative time, and thereby reducing day-to-day operating costs, helped provide a return-on-investment justification for the purchase.

Get your surgeons to standardize their protocols. As we've said, keeping processes consistent from case to case and day to day is a key factor in maintaining efficiency. Standardization is relatively easy to enforce among your staff, but often more difficult when it comes to your surgeons. If you have more than 1 cataract surgeon at your facility, try to get them to standardize their dilating protocols, lens preferences and instrumentation. At our facility, this was easy in the beginning because we only had 2 cataract surgeons, and they were a father-and-son team. We've since added 2 more cataract surgeons and are slowly trying to get them to adopt the same protocols.

Don't force the issue or immediately demand standardization. Start by simply approaching your surgeons, letting them know how things are usually done at your facility and asking them if they'd be willing and able to standardize. If you state your case in the right manner and give them time to adjust, the surgeons should be willing to comply.